Minimal touch surgical implantable cardioverter defibrillator implantations
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《血管的通路杂志》
Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
Abstract
A growing number of patients with contraindication for transvenous implantable cardioverter defibrillator (ICD) implantation or need for system upgrade of a pre-existent pacemaker system is to be observed. Therefore, unconventional system constellation may be necessary to provide patient safety by using a minimal invasive access avoiding sternotomy. Two similar cases are presented to demonstrate configuration solutions which can be easily individually modified. Simple pacemaker and ICD implantation is nowadays mostly performed by cardiologists and/or general surgeons. As soon as partial or total thoracotomy becomes necessary, the patient will be referred to a department of cardiac surgery. Hence, in the very near future, cardiac surgeons will face a large number of redo procedures for pacemaker- and ICD systems including the necessity for mixed transvenous and epicardial solutions. To avoid significant morbidity deriving from sternotomy and pericardiotomy, concepts for as less invasive as possible solutions are presented.
Key Words: Pacemaker; Implantable cardioverter defibrillator; Implantation technique; Lead placement; Education
1. Introduction
The medical community is facing a substantial increase of pacemaker and ICD implantations. Future consequences like a growing number of complications arising from implantation-related techniques, and long-term side-effects of leads and devices such as complete venous obstruction, actually creates another demanding part of cardiac surgery. The aim is to focus on the necessity to maintain all applicable implantation techniques at a high level to enable the cardiac surgeon to find optimal solutions for the patient who requires a pacemaker or ICD system.
2. Patients and methods
We describe the circumstances and implantation technique in two patients with so far unconventional, but very likely not unique constellation of ICD systems.
3. Results
Two examples of recent unconventional ICD implantation illustrate the close relationship between routine and challenge ICD implantation out of the cardiac surgeon's view. Although the presented cases demonstrate the surgical technique, pacemakers can be placed similarly without the necessity of subcutaneous shock coil placement.
3.1. Patient 1
A 69-year-old female, ischemic cardiomyopathy, severely impaired left ventricular function (EF 21%), NYHA III, positive echocardiographical signs of asynchrony, high-degree stenosis of the superior vena cava, coronary three-vessel disease, CABG in 1994 and redo CABG in 2002, chronic atrial fibrillation, chronic renal insufficiency (dialysis-dependent), insulin-dependent diabetes. Via subxiphoidal incision (6 cm), two unipolar epicardial RV leads were placed (Biotronik 35 UP). Because of severe adhesions after redo CABG three years previously, the left ventricular unipolar epimyocardial lead (Biotronik 35 UP) was implanted via left anterior minithoracotomy (5 cm). A third, 5 cm incision subcostal left allowed the proper placement of the biventricular ICD device (Medtronic 7304). Through the subcostal incision, both of the subcutaneous single coil leads (Medtronic 6996) were placed (parasternal left, dorsolateral left (Fig. 1). Both of the RV leads were connected via a 2 x IS-1 unipolar- 1 x IS1-bipolar adaptor to the ICD device. Sensing was 6.0 mV, and pacing threshold 0.6 V/0.5 ms (impedance 581 ). Because of the extremely impaired general status of the patient before surgery, testing was performed successfully twice, using 18 Joules (inactive can).
3.2. Patient 2
A 55-year-old female, status after mechanical tricuspid valve replacement in 2000; routinely, two epicardial RV leads (Biotronik 35 UP) had been implanted during operation. Four years later, the patient underwent successful reanimation for ventricular fibrillation without any preceding symptoms. So, a class I indication for ICD implantation was present. As an alternative to complete resternotomy, a 5-cm subcostal incision using the same scar of the RV lead end placement was used for implantation of the total ICD system. An adaptor was used to obtain a (true) bipolar connection of the two already implanted unipolar RV leads. Chronic lead parameters were: sensing 9.3 mV, pacing threshold 1.4 V/0.5 ms, impedance: 567 . Thereafter, two single subcutaneous finger leads (Medtronic 6996) were placed in the parasternal left and dorsolateral left position (Fig. 2) from the same incision. The ICD device (Medtronic 7232) was programmed inactive and twice a safety margin of 20 Joules could be confirmed during DFT testing (15 Joules effective). Shock and pacing impedance is stable for over 3 years.
4. Discussion
Pacemaker and ICD implantation is often regarded as a simple and easy procedure, ideal for beginners in cardiac and general surgery. Especially device exchange without the necessity of lead replacement is often given to less experienced surgeons. Not only a lack of knowledge about older connector standards (3.2 low profile, 5/6 mm), or unconventional connector/lead fixation, or simply the difference between unipolar and bipolar pacing mode in pacemaker-dependent patients may lead to major problems. In the NASPE training requirements for cardiac implantable electronic devices, the most recent surveys indicate the proportion of devices implanted by cardiologists to be at 75% in the United States [1]. The given statement, that thoracotomy as the initial route of pacemaker and ICD insertion has been supplanted by the transvenous approach, except in special circumstances, is perhaps true for the moment. We face a still rising number of implantations in patients with longer life expectancy compared to the systems implanted in the late 1980s or early 1990s. The need for more profound consideration of possible ICD configurations becomes obvious. Combining epimyocardial minimal invasive access with subcutaneous placement of shock coils represents an alternative of conventional sternotomy to apply a full epimyocardial ICD system as performed in the beginning of the ICD era. Meanwhile, construction and material of the leads have become a major issue, especially in view of the increasing number of prophylactic indication. Our own experience on subcutaneous finger leads in conventional position accounts for about 400 over the past 5 years; so far we observed no lead fracture but 2 cases of lead dislodgement leading to a substantial loss of DFT during the first year after implantation in the first series. After changing the lead placement of the subcutaneous finger lead from subcutaneous to submuscular, no further event occurred so far. Although reports about accidental perforation of the thoracic wall up to spleen injury exist, an implantation-related injury of thoracic or abdominal structures did not occur in the whole series, neither in subcutaneous nor in submuscular finger lead implantation. According to reports and our own experience concerning longevity and reliability of subcutaneous finger leads, and the epimyocardial RV- and LV-lead, the present configuration seems to be a reliable and practicable implantation method.
References
Hayes DL, Naccarelli GV, Furman S, Parsonnet V, Reynolds D, Goldschlager N, Gillette P, Maloney JD, Saxon L, Leon A, Daoud E. NASPE training requirements for cardiac implantable electronic devices: selection, implantation, and follow-up. PACE 2003; 26:1556–1562.(Brigitte R. Osswald, Ursu)
Abstract
A growing number of patients with contraindication for transvenous implantable cardioverter defibrillator (ICD) implantation or need for system upgrade of a pre-existent pacemaker system is to be observed. Therefore, unconventional system constellation may be necessary to provide patient safety by using a minimal invasive access avoiding sternotomy. Two similar cases are presented to demonstrate configuration solutions which can be easily individually modified. Simple pacemaker and ICD implantation is nowadays mostly performed by cardiologists and/or general surgeons. As soon as partial or total thoracotomy becomes necessary, the patient will be referred to a department of cardiac surgery. Hence, in the very near future, cardiac surgeons will face a large number of redo procedures for pacemaker- and ICD systems including the necessity for mixed transvenous and epicardial solutions. To avoid significant morbidity deriving from sternotomy and pericardiotomy, concepts for as less invasive as possible solutions are presented.
Key Words: Pacemaker; Implantable cardioverter defibrillator; Implantation technique; Lead placement; Education
1. Introduction
The medical community is facing a substantial increase of pacemaker and ICD implantations. Future consequences like a growing number of complications arising from implantation-related techniques, and long-term side-effects of leads and devices such as complete venous obstruction, actually creates another demanding part of cardiac surgery. The aim is to focus on the necessity to maintain all applicable implantation techniques at a high level to enable the cardiac surgeon to find optimal solutions for the patient who requires a pacemaker or ICD system.
2. Patients and methods
We describe the circumstances and implantation technique in two patients with so far unconventional, but very likely not unique constellation of ICD systems.
3. Results
Two examples of recent unconventional ICD implantation illustrate the close relationship between routine and challenge ICD implantation out of the cardiac surgeon's view. Although the presented cases demonstrate the surgical technique, pacemakers can be placed similarly without the necessity of subcutaneous shock coil placement.
3.1. Patient 1
A 69-year-old female, ischemic cardiomyopathy, severely impaired left ventricular function (EF 21%), NYHA III, positive echocardiographical signs of asynchrony, high-degree stenosis of the superior vena cava, coronary three-vessel disease, CABG in 1994 and redo CABG in 2002, chronic atrial fibrillation, chronic renal insufficiency (dialysis-dependent), insulin-dependent diabetes. Via subxiphoidal incision (6 cm), two unipolar epicardial RV leads were placed (Biotronik 35 UP). Because of severe adhesions after redo CABG three years previously, the left ventricular unipolar epimyocardial lead (Biotronik 35 UP) was implanted via left anterior minithoracotomy (5 cm). A third, 5 cm incision subcostal left allowed the proper placement of the biventricular ICD device (Medtronic 7304). Through the subcostal incision, both of the subcutaneous single coil leads (Medtronic 6996) were placed (parasternal left, dorsolateral left (Fig. 1). Both of the RV leads were connected via a 2 x IS-1 unipolar- 1 x IS1-bipolar adaptor to the ICD device. Sensing was 6.0 mV, and pacing threshold 0.6 V/0.5 ms (impedance 581 ). Because of the extremely impaired general status of the patient before surgery, testing was performed successfully twice, using 18 Joules (inactive can).
3.2. Patient 2
A 55-year-old female, status after mechanical tricuspid valve replacement in 2000; routinely, two epicardial RV leads (Biotronik 35 UP) had been implanted during operation. Four years later, the patient underwent successful reanimation for ventricular fibrillation without any preceding symptoms. So, a class I indication for ICD implantation was present. As an alternative to complete resternotomy, a 5-cm subcostal incision using the same scar of the RV lead end placement was used for implantation of the total ICD system. An adaptor was used to obtain a (true) bipolar connection of the two already implanted unipolar RV leads. Chronic lead parameters were: sensing 9.3 mV, pacing threshold 1.4 V/0.5 ms, impedance: 567 . Thereafter, two single subcutaneous finger leads (Medtronic 6996) were placed in the parasternal left and dorsolateral left position (Fig. 2) from the same incision. The ICD device (Medtronic 7232) was programmed inactive and twice a safety margin of 20 Joules could be confirmed during DFT testing (15 Joules effective). Shock and pacing impedance is stable for over 3 years.
4. Discussion
Pacemaker and ICD implantation is often regarded as a simple and easy procedure, ideal for beginners in cardiac and general surgery. Especially device exchange without the necessity of lead replacement is often given to less experienced surgeons. Not only a lack of knowledge about older connector standards (3.2 low profile, 5/6 mm), or unconventional connector/lead fixation, or simply the difference between unipolar and bipolar pacing mode in pacemaker-dependent patients may lead to major problems. In the NASPE training requirements for cardiac implantable electronic devices, the most recent surveys indicate the proportion of devices implanted by cardiologists to be at 75% in the United States [1]. The given statement, that thoracotomy as the initial route of pacemaker and ICD insertion has been supplanted by the transvenous approach, except in special circumstances, is perhaps true for the moment. We face a still rising number of implantations in patients with longer life expectancy compared to the systems implanted in the late 1980s or early 1990s. The need for more profound consideration of possible ICD configurations becomes obvious. Combining epimyocardial minimal invasive access with subcutaneous placement of shock coils represents an alternative of conventional sternotomy to apply a full epimyocardial ICD system as performed in the beginning of the ICD era. Meanwhile, construction and material of the leads have become a major issue, especially in view of the increasing number of prophylactic indication. Our own experience on subcutaneous finger leads in conventional position accounts for about 400 over the past 5 years; so far we observed no lead fracture but 2 cases of lead dislodgement leading to a substantial loss of DFT during the first year after implantation in the first series. After changing the lead placement of the subcutaneous finger lead from subcutaneous to submuscular, no further event occurred so far. Although reports about accidental perforation of the thoracic wall up to spleen injury exist, an implantation-related injury of thoracic or abdominal structures did not occur in the whole series, neither in subcutaneous nor in submuscular finger lead implantation. According to reports and our own experience concerning longevity and reliability of subcutaneous finger leads, and the epimyocardial RV- and LV-lead, the present configuration seems to be a reliable and practicable implantation method.
References
Hayes DL, Naccarelli GV, Furman S, Parsonnet V, Reynolds D, Goldschlager N, Gillette P, Maloney JD, Saxon L, Leon A, Daoud E. NASPE training requirements for cardiac implantable electronic devices: selection, implantation, and follow-up. PACE 2003; 26:1556–1562.(Brigitte R. Osswald, Ursu)